Basic Information
| Provider Information | |||||||||
| NPI: | 1093191777 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HENEMAN | ||||||||
| FirstName: | AUSTIN | ||||||||
| MiddleName: | JAMES | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7225 OHMS LN STE 150 | ||||||||
| Address2: | |||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554392172 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528412345 | ||||||||
| FaxNumber: | 9528412346 | ||||||||
| Practice Location | |||||||||
| Address1: | 7270 FORESTVIEW LN N STE 100 | ||||||||
| Address2: | |||||||||
| City: | MAPLE GROVE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528412345 | ||||||||
| FaxNumber: | 9528412346 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2015 | ||||||||
| LastUpdateDate: | 08/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2314 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.